MAR chart gaps: what to look for and how to fix them before a CQC inspection

When an inspector sits down with your medicines records, they aren’t looking for perfection. They’re looking for a record that tells a reliable story: each person got the right medicine, at the right time, in the right way, and when something went wrong, someone noticed and acted.

I have spent more than 22 years in medicines, across NHS hospital trusts, community pharmacy, private healthcare and NHS medicines support for social care. In that time I’ve reviewed a great many Medication Administration Records (MARs), paper and electronic, and the same handful of gaps come up again and again. None of them needs an expensive fix. A manager can find all of them in a short weekly check.

Blank boxes and unexplained codes

A blank box on a MAR is the most common gap, and the most damaging, because nobody can interpret it. Was the dose given and not signed for? Was it refused? Was it left out because the person was in hospital? An inspector can’t tell, and neither can the next member of staff.

Codes cause a related problem. “R” for refused or “O” for other only helps if the code key is on the chart and the reason is written down. NICE guidance for care homes says staff should record when and why medicines have not been given. A run of “O” codes with no explanation reads as poor practice even when the care was good.

Corrections matter too. NICE asks for mistakes to be corrected with a single line through them, followed by the correction, a signature, the date and the time. Correction fluid should never be used.

“When required” (PRN) medicines without a protocol or an outcome

PRN medicines, such as pain relief, laxatives and medicines for agitation or anxiety, need a clear, person-centred process. NICE recommends that it covers:

• the reasons for giving the medicine
• how much to give if a variable dose is prescribed
• what the medicine is expected to do
• the minimum time between doses if the first dose hasn’t worked
• offering the medicine when it’s needed, not just at medication round times
• when to check with the prescriber

The best PRN protocols also describe how this person shows they need the medicine, which matters most when they can’t tell you.

NICE also asks staff to record PRN medicines only when they are given, noting the dose given and, where possible, the amount left. Good practice goes one step further: record the outcome. If paracetamol was given for pain at 2pm, did it work? Without outcomes nobody can spot that a person is in ongoing pain, or that a sedating medicine is being used far more often than intended.

Handwritten MAR entries without a second check

When a new medicine starts mid-cycle, perhaps after a GP visit or a hospital discharge, staff often handwrite it onto the MAR. Transcribing is one of the highest-risk moments in the whole medicines process. A misread dose or a missed “stop” instruction can carry on for weeks.

NICE says a handwritten MAR should be produced only in exceptional circumstances, by a member of staff with the training and skills to manage medicines. It should then be checked for accuracy and signed by a second trained and skilled member of staff before it is first used.

Stock that doesn’t match the record

If a MAR shows a tablet signed for twice daily over 14 days, there should be 28 fewer tablets than were received and carried forward. When the count doesn’t match, either doses were missed and signed for anyway, or doses were given and not signed for. Both matter.

Controlled drugs get the most attention, but stock balances for other medicines can reveal recording problems too. That’s especially true for medicines where a missed or extra dose carries real risk, such as anticoagulants, insulin, anti-epileptics and medicines for Parkinson’s.

Allergies, timing and covert administration

A 15-minute weekly spot-check

You don’t need a full audit every week. A registered manager or senior carer can do this in about 15 minutes:

1. Pick two people at random and scan their current MARs for blanks and unexplained codes.
2. Pick three PRN medicines and check the protocol, the reason, the dose and the outcome.
3. Check every handwritten entry for its source and a second signature.
4. Count two medicines against the MAR.
5. Write down what you found, what you did about it and who you spoke to.

That last step is what turns a check into evidence. Inspectors want to see that your service finds its own problems.

For a fuller approach, see our step-by-step guide on how to audit MAR and eMAR records.

Learning from medication errors, not just recording them

Every service has medication errors and near misses. NICE expects a robust process for identifying, reporting, reviewing and learning from them. A strong error record shows:

• what happened, and what was done straight away to keep the person safe
• whether the GP, pharmacist or NHS 111 was contacted, and what they advised
• the likely cause, looking at the system and not just the individual
• what changed as a result, and how you checked the change worked

If the same type of error keeps appearing, that’s a pattern. It’s a sign that training, the process or the environment needs to change. Interruptions are a common culprit: NICE suggests avoiding planned staff breaks during medicines rounds and cutting distractions for the staff giving medicines. If you need support after an incident, see our medication error review and support.

Training, knowledge and competence

Finally, remember where training ends. Training and knowledge checks help staff understand safe medicines practice. But NICE is clear that care home providers must make sure staff give medicines only once they have had the necessary training and are assessed as competent, with an annual review of their knowledge, skills and competencies. Assessing and confirming that competence in your service is the provider’s responsibility. Inspectors will ask how you know your staff are competent, and a training certificate on its own doesn’t answer that question.

Good MAR charts aren’t paperwork for its own sake. They are the record that the people you support received their medicines safely, and small, regular checks keep them that way.